Coroner's Finding: Hill, James Fredrick
Deceased
James Fredrick Hill
Demographics
74y, male
Date of death
2021-12-16
Finding date
2024-10-10
Cause of death
small intestinal ischaemia caused by aortic atherosclerosis
AI-generated summary
A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clear warning signs and abnormal blood tests indicating infection and organ dysfunction, a MET call was not made for 18 hours. The underlying ischaemic bowel was not diagnosed until 9pm when he was critically ill with septic shock and multiple organ failure. By then, his entire small intestine was dead and surgery could not save him. Key failures included: not investigating the cause of hypotension, normalising low blood pressure parameters, calling the HMO instead of MET, and failure to transfer to ICU when clinically indicated. Earlier recognition and ICU transfer at 3:30am would have provided a greater chance of survival through timely surgery before complete intestinal necrosis.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to recognise sepsis
- delayed diagnosis of ischaemic bowel
- failure to call MET team when clinically indicated
- delayed transfer to intensive care unit
- failure to investigate underlying cause of hypotension
- inappropriate modification of blood pressure parameters without documented reasoning
- culture of calling HMO instead of MET
- inadequate initial assessment and baseline investigations in emergency department
- poor communication between orthopaedic and medical teams
- staff unfamiliarity with MET escalation process
- inadequate staffing and heavy patient load affecting MET response capability
Coroner's recommendations
- Recognition and treatment of sepsis protocols
- Education on MET calling and functions
- Modification of observation parameters and documentation of reasoning
- Staff escalation procedures for patient concerns
- Admission processes including documentation, comprehensive assessment, and investigation of underlying causes of falls
- Baseline investigations including blood tests in emergency department
- Investigation of unexplained hypotension
- ICU transfer protocols for unstable patients
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